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RESOLUTION NO. 29-03/04
�� A RESOLUTION OF THE VII,LAGE COUNCIL OF
THE VII.LAGE OF TEQUESTA, PALM BEACH
`� COUNTY, FLORIDA, NAMING DANIEL J.
GALLAGHER, RISK MANAGEMENT
COORDINATOR, AS THE DESIGNATED PLAN
' COORDINATOR OF THE ICMA (INTERNATIONAL
�;
�' CITY/COUNTY MANAGEMENT ASSOCIATION)
RETIItEMENT PLAN FOR ENROLLED VII�LAGE
EMPLOYEES.
`' WHEREAS, the ICMA Retirement Plan is an optional 457 Investment Plan for
;' the all of the Village's employees; and
i:
WHEREAS, Daniel J. Gallagher, Risk Management Coordinator, will be
:' responsible for signing disbursement and loan withdrawal forms, authorizing any
`' disbursement or loan transactions and answering questions pertaining to disbursement
': and loans; and
WHEREAS, Daniel J. Gallagher, Risk Management Coordinator, will be
;` responsible for sending contributions to ICMA, and resolving discrepancies; and
NOW, THEREFORE, BE IT RESOLVED THAT DANIEL 7. GALLAGHER, RISK
' MANAGEMENT COORDINATOR WII,L BE THE DESIGNATED PLAN
''? COORDINATOR OF THE ICMA RETIREMENT PLAN.
;:;
THE FOREGOING RESOLUTION WAS OFFERED by Council Member
, who moved its adoption. The motion was seconded by Council
; Member , and upon being put to a vote, the vote was as follows:
FOR ADOPTION AGAlNST ADOPTION
'' The Mayor thereupon declared this Resolution duly passed and adopted this ll day of
'�; March, 2004.
Mayor of Tequesta
Village Clerk Mary Miles
81/29/B4 89:14:45 RightFax-> 5615756283 Fax Seruer Page �2
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ICMA �tETIREMENT CORPORATION
PLAN�LEVEL CHANGE FORM
ICMA RE7IREMElIff CORPORATION
This form may be used by employers and ICMA Retinement Corporation
personnel tc request plan-level updates for ICMA-RC records. When compieting
this farm, tha following actions should be taken:
(1) Enter ihe changes needed in the appropriate section(s} on the opposite side of this twcrpage, two-part form.
(2} Enter any special instructions in the Comments section of the form's second page.
(3} Pleasc� complete the information on the top of each page as the person requesting this record update.
{4j Forw:ird tl�e completed fvrms ta Attn: New Business Unit orfax to: Attn: New Business Unit
ICMA Retirement Corporation 1-202-962-4601
777 Nonh Capitoi Street, NE
Washington, DC 20090-6220
Your changE�s shouid appear an our recordkeeping sysiem appraximately five days fram receipt of the praperly
compi�ed fi�rms. Thank you for you� cantinued participatian in the �tiremerrt plan. We loak forward to cantinuing to �
develop methods to administer your aocour� in tF�e most efficient manner passible. Please contact our Employer
Services Unit at 1-800-326-7272 with any questions.
When campieting this farm please cleariy prirx yaur employer name and ICMA-RC plan accaunt number on the top of
both pages. �ince there may be other plans with the same name in other states, it is imperative that you give us
accurate anci complete information to ensure yaur changes are made to the proper account.
The followir�g designatiar�s shoufd be noted accordingly:
Primary Cta�tsct
This is the person responsible forthe day-to-day administration and processing of ICMA-RG transactions. This is the
oerson we call if general questions arise concerning your ICMA-RC account.
Disburseen�.�ntlLoan
This person (arthese persons} will be respansible forsigning disbursement and loan withdrawal forms, authorizing
any disbursemerx or loan uansactions arxl answering questions pertaining to disbursemenis and foans. This should
be a person(s) of authority. Alsa, the signature(s) of the designated person(s} should be placed in the appropriate
section of this form for our reference purposes.
Ca�ntri6uti�.�n
lhe person ��esponsible for sending contributions to ICMA-RC. If there are discrepancies in the actual check or wir+e
amounts arkl the corresponding back up, this is the persan we will contact to nesolve the issue. This person should
have access to all payroll/contribution information to ensure efficient processing of contributions.
TapdDiske tt�
This person has the same duties as the contribution oontact, except we will notify this designee if the tape or diskette
is damaged, the tape/diskette is not in an acceptable format orthe informatia� on the tapeldiskette is not usable.
Quarter'ly .�`ataternent
This person vvill receive all quarterly statements.
Plan CoorcE�nator
The title of ti�is person is designated in the resolution. If a different person obtains the same title, yau may use this
form ta update the name change. You must have your legislatnre body pass a new r�esoJution to update il�e tit�e of
the person clesi�ted as plan coondirtator.
Bi��ing (FcE3)
This person �vill receive the invaices if ICMA-RC charges any emplayer-paid fees ta your account.
temittana:: Racanciliatian
(his should ue tF� same persan as the contribution contact. Canfirmations for contributions r�ceived are sent to this
individual.
FRAAOOD-016•200105�505
ICMA Retirem�nt Corpcxation • 777 North CapRol Street, NE • Washington, DC 20002-4240 • Toll Free 1-800-326-7272
81/Z9/B4 89:15:44 RightFax-> 5615756ZB3 Fax Seruer Page 8B3
ICMA-i�C Plan-Level Change Form, Page 7 of 2
Employer iUame: ✓� �, [, � „�� E - � f �� � �-�,��
r J�B�e: �� Plan Number. Date ICMA RETIREIYIENTCORPORATqN
Emplayer'� Signature:
Title of Err�ployerAuthorized O icial (PI 'ruj: _ ?1/_�.� n.r,46['��•� �-A/_�,cC-�R
_'
ICMA-RC E�ssociate: Date:
G ��� (902J Plan Name:
�^fOr'^$` (924J StreetAddress: �So '1Z�fJiJ�'S7`A DR l ✓L�
(szs)
(9T 8J City: l'L�b�� r_ -r�1
(919J State: �G o R� 7 4
(920J Zip Code: �� � yt(�4
"Forefeitwe Account (999-99-9999) must be updated. This refers to 401 pians on1y,
�°'� (633) Corrtad Narr�: ��.nn! i Cl. J .�rAL L f� �ffc'7Z
Cartitact
a�orma�� (s341 Corrtad Title: ?zi Si� .N/AN,4 ��y��lT .��rz �cr`���°�
(631) Tetephone: ( .�� / ) .�'zS - � 2 d �"f
(632) Fax: �
} C�1��=�- �,?_Q 3
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� Disburser:�erk AD01 Corrtact Signature: �
Y /Loan -
? �� (200) Contad Narne: i � �`
� b7farmat.ion �-
V (ZO0) Corrtact Title:
g P�BBSB rJ� (JLP/ ) �fYi�'„ � r �S /7 r' :-°" � 4f
a0 �dicate (420) Tele �..� n. L � Fax �� J�r: -• � tiC3 .-
(� atternatE:
Z addresst:s qpp8 Contad Signaitre:
V� in
� Commei�ts (200) Contact Name:
Z Seciion un
� Page 2 l200) Corrtact Title:
a (420) Telephone: L� Fax:��
W
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� A009 Contact Signature:
a (zoo� Contact Name:
(200) Contact Title:
(420) Telephone: �� Fax:(_ )
Convibation ADOZ (200) Contact Name: ,�'1/ GN�1.[�c° .Z?oi�E"«
� � .Z
��� (zoo) Contad Trtle:
Informat�on
(4zo) Telephone: �( ' g / 1 '�"� 2 d �' Fax: ( � / ) .T'� � -- � ."� _ 3 2.�
T� AD03 (200) Cor�tact Narne:
Diakette
Cwuact (200) Contact Title:
Mormat;on �
(4zo) Telephone: �) Fax(_�
Q���� A0o4 (200) Contact Name:
Statement
Caxace (200) Corrtact Title:
Information
(420) Telephone: �) Fax;(_,
ICMA Retiren �ent Corporation • 777 North Capitol Street, NE • Washa�gton, � 20002-4240 • Totl Free 1-8D0-326-7272 FRNqD0016dOD105
E�dernal Use: 1st Copy • ICMA Retrcement Corporetion's Copy 2nd Copy • Employer's Copy
Internal Use: 1at Copy • New Business Unit's Copy 2nd Capy • ICMA-RC Associate's Copy
81/29/B4 89:16:12 RightFax-> 5615756Z83 Fax Seruer Page 884
ICMA��tC Plan-Level Chanse Form, Pase 2 of 2
Employer idame: ���-�. A�'E ezE- 3L�v ��T.�
State: �� Plan Number. Date ICMA RETIREMEIrTCORPORAT1pN
Employer's� Signature:
Title of Emaloyer Authorized O��ial (Pleas� rint):
ICMA-RC Associate: Date:
AD05 (ZOOJ Co�1taCI Name:
Plan
• Coordin.�tor �ZOO� COnteCt Tltle:
concacc Note; Changing this title requires an amendment to your resolution.
Infonnaeion �420) Telephone: L_} Fax: (_}
Bining q p� (200) Contact Name: /t'�l �N-s�,L� /�1 �,D�,v✓�z �--
(Fees)
��� (200) CorKad Title: �
Intormauon (420) Telephone: (�L.} �' 0 Fax:( .'�O � ) .� �.5� - l 2.3 2.
Remiceat�co ,qoo� (2mo) Contact Name: �, d.� � z-�� :/��..���L-
Reconcii�a
ua+ (200) Contact Title:
cauacc
IMonnat;on (4zo1 Telephone: {,�o � ? ��S -G 7..� � Fax:( ' � l � �`.L'�^/ z Z,
� �°"«'b''ti°" (s23) � Submittal Document {Sy � Tape(» ❑ EDT (Eledronic Data Transmission} (E�
Z Medium
0 ❑ Diskette (� ❑ ICMA-RC Quickdisk (Q) d Cartridge Tape t�c} d EZ Link (�
Y
Z
Y Submittai
G� Dacumc.nt (6231 ❑ WITH contribution dallar amounts (� ❑ WITHOUT contribution dollar amounts (2)
m �'"t Note: This appJies on/y to Submitta! Documents_
�7
� � (624) 0 Check (G� d ACH (Automatic Ciearing House) (R)
D�t
� M�+� ❑ Wire (UV) ❑ EFT {Electronic Fund Transfer� {E�
Z
a
d
W Convibuuon (6�71 d Bi-weekly (O} ❑ Mor�hiy (4) ❑ Quarterly (�
� F�aq"e"`'y a Weekly (n ❑ Semi-rrronthly (� ❑ Annually (1�
a
S"b""a� (s�2) ❑ Name (11�j ❑ Social Sec�ity Number (S�
Docume.�t
Sort Order
4uanen�
���"E�u (s2s) a Detail (D} ❑ Summary {Sy
Repart
Options
4uarte�l'l
sacemenc (szs) d Sacial Security Number (Sj 0 Name (IVj
Sort Order
Comma as
ICMA Retirernent Corporatian • 777 North Capitol Street, NE • Washington, � 20002-9240 • ToU Frce 1-800-326-7272
fRnnooam szom assos
External Use: 1s[ Copy • ICMA Ret�ement Corporatlon's Copy 2nd Copy • Empioyer's Copy
Internal Use: 7at Cop�l • New Business Unit's Copy 2nd Capy • ICMA-RC Associate's Copy